HAMILTON COUNTY...Very Preterm Birth Rate Surveillance Chart, Hamilton County, July 2016 - Aug 2018* Figure 5.

HAMILTON COUNTY

August 2018

Maternal and Infant Health Monthly Surveillance Report

Whitney Rémy, MPH, Epidemiologist Thomas Boeshart, MPH, Senior Epidemiologist

INTRODUCTION

INFANT MORTALITY SURVEILLANCE

The Maternal and Infant Health Monthly Surveillance Reports are part of work throughout Hamilton County to improve the health of women and infants, and to lower the number of infant deaths. In order to improve the health and safety of infants in Hamilton County, it is important to identify, describe, and track the problems and people at risk. This report shows the current state of infant mortality in Hamilton County.The data for these reports has been enhanced to improve the monthly tracking process. The Ohio Department of Health (ODH) provides monthly death data to Hamilton County Public Health that is used to improve the timeliness and accuracy of the monthly data. These data were provided by the Ohio Department of Health. The Department specifically disclaims responsibility for any analyses, interpretations or conclusions. These data are provisional and are numbers only; they do not include any additional information from birth or death certificates (Appendix A). Future reports will provide improved validity of these estimates (Appendix A). Death data in this report were collected from ODH on January 10th, 2019; birth data were collected from the Ohio Public Health Information Warehouse on January 14st, 2019.

Public Health surveillance is the ongoing systematic collection, analysis, interpretation and dissemi-nation of data regarding health-related events for use in public health action to decrease sickness and death, and improve health1. The Maternal and Infant Health Surveillance System is designed to better understand infant health in Hamilton County, track infant deaths and determine whether the ongoing work in Hamilton County to prevent infant deaths are effective. The charts used within this report are surveillance charts, which are tools to monitor infant health in Hamilton County. Comparisons to the national Healthy People 2020 Goals are made when possible. Healthy People 2020 Goals are a set of nationwide goals that support prevention efforts to create a healthier nation. These goals are released every 10 years from the US Department of Health and Human services. For more information about how to understand the surveillance charts, please read the General Guidelines for Using Surveillances Charts in Appendix B.

1. Centers for Disease Control and Prevention. Updated Guidelines for Evaluating Public Health Surveillance Systems: Recommendations from the Guidelines Working Group, MMWR, July 27,2007, Vol. 50 No. RR-13.

August 2018, Page 1

The Maternal and Infant Health Monthly Surveillance Report will include the following topics:

• Number of infant deaths by month• Current monthly infant mortality rate• Current monthly neonatal mortality rate• Current monthly preterm, very preterm, and <23 weeks gestation birth rate• Current monthly small for gestational age birth rate

• Percentage of pregnancies spaced <18 months• Maternal smoking rates• Number of sleep-related deaths• Current two-year infant mortality rate moving average• Comparison of “Filed” and “Unfiled” data

NUMBER OF INFANT DEATHS

INFANT MORTALITY

One way to look at infant health is to track the number of infant deaths in Hamilton County per month. Infant deaths are the death of a child before his or her first birthday. In August 2018, there were six infant deaths in Hamilton County. One of the infant deaths that occurred in August 2018 in Hamilton County, occurred among Cincinnati residents. Table 1 displays the provisional number of infant deaths and births for each month in 2017 and 2018. To learn more about provisional death data and it’s limitations, please see Appendix A on Page 13.

Another way to measure infant health is to track the Infant Mortality Rate (IMR) per month. An infant mortality rate is the number of infant deaths for every 1,000 live births. The Neonatal Infant Mortality Rate (NIMR) is a specific IMR for neonates (infants who are younger than 28 days). A neonatal infant mortality rate is the number of neonatal deaths for every 1,000 live births. An infant mortality rate is highly sensitive to changes in the number of births within a community, and it may not be surprising to have an increase in the number of infant deaths if there is also an increase

in the number overall babies being born.The IMR for August 2018 was 6.1 infant deaths per 1,000 live births (Figure 1). The August IMR is slightly higher than the Healthy People 2020 goal of 6.0 infant deaths per 1,000 live births as shown in Figure 1. The August 2018 NIMR was 3.1 neonatal deaths per 1,000 live births (Figure 2). The August NIMR was lower than the Healthy People 2020 goal of 4.1 neonatal deaths per 1,000 live births. Neonatal deaths make up 76% of infant deaths in Hamilton County from January 2017 - August 2018. As can be seen from comparing Hamilton County rates and national infant health goals, Hamilton County is experiencing problems within the community regarding maternal and infant health.

August 2018, Page 2

Table 1. Number of Infant Deaths and Births, Hamilton County, 2017-2018

Infant Deaths, Hamilton County 2018 Year-to-date68

33Infant Deaths,

Cincinnati 2018 Year-to-date

6.1 per 1,000August 2018 IMR

This provisional rate was higher than the Healthy People 2020 goal (6.0)

2017 2018

Infant Deaths

Live Births

Infant Deaths

Live Births

January 6 845 10 857

February 6 897 9 795

March 6 788 12 903

April 9 898 8 874

May 8 835 7 888

June 8 922 7 889

July 10 930 9 851

August 12 941 6 978

September 6 990

October 8 948

November 7 935

December 9 813

Total 95 10,768 68 7,035

13.2

9.4 6.7

11.212.7

5.8 6.77.6 6.7

10.8

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6.3

9.68.6

11.4 11.7 11.313.3

9.27.9 7.9

10.6

6.1

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5

10

15

20

25

30

35

40

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Monthly IMR Healthy People 2020 Goal (6.0) Average (9.5) Control Limits

8.87.3

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8.9

11.6

2.3

4.56.3

5.6

9.6

6.5

8.6 8.5

10.1

4.2

8.5

6.2 6.98.2

11.3 11.1

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Monthly NIMR Healthy People 2020 Goal (4.1) Average (7.3) Control Limits

August 2018, Page 3

Figure 1. Infant Mortality Rate Surveillance Chart, Hamilton County, July 2016 - Aug 2018*

Figure 2. Neonatal Mortality Rate Surveillance Chart, Hamilton County, July 2016 - Aug 2018*

NOTE: The mean is calculated using two years of data from Jul 2016 - Jun 2018. Orange points are more likely to change in future reports. *Data for 2018 are provisional; ODH reconciles (i.e. finalizes) data by fall of the subsequent year.Data Source: ODH Vital Statistics


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Monthly Percent Healthy People 2020 Goal (9.4) Average (11.1) Control Limits

PRETERM, VERY PRETERM, & <23 WEEKS GESTATION BIRTH RATES

A preterm birth is the birth of a baby that happens more than three weeks before the baby is due. A preterm birth rate is the percent of babies who are born before the start of the 37th week of pregnancy. The very preterm birth rate is the percent of babies who are born before the start of the 32nd week of pregnancy. The <23 weeks gestation birth rate is the percent of babies who are born before the start of the 23rd week of pregnancy. The <23 weeks gestation birth rate is important to track as approximately 1/3 of all infant deaths in Hamilton County each year are from babies who are born before the start of the 23rd week of pregnancy. Preterm birth increases the chance for infant death and many other poor health outcomes. The preterm birth rate for July 2018 is 12.4%; this rate is also above the average preterm birth rate in Hamilton County (11.1%). The very preterm birth rate for July 2018 (0.9%) was lower than the Hamilton County average (2.0%). The <23 weeks gestation birth rate for July 2018 is 0.10%, which is higher than the Hamilton County average (0.31%).

August 2018, Page 4

Figure 3. Preterm Birth Rate Surveillance Chart, Hamilton County, July 2016 - Aug 2018*

NOTE: The mean is calculated using two years of data from Jul 2016 - Jun 2018 Orange points are more likely to change in future reports. *Data for 2018 are provisional; ODH reconciles (i.e. finalizes) data by fall of the subsequent year.Data Source: ODH Vital Statistics

12.4%August 2018

Preterm Birth Rate

0.9%August 2018 Very Preterm

Birth Rate

2.0

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Monthly IMR Average (2.0) Control Limits

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August 2018, Page 5

Figure 4. Very Preterm Birth Rate Surveillance Chart, Hamilton County, July 2016 - Aug 2018*

Figure 5. <23 Weeks Gestation Birth Rate Surveillance Chart, Hamilton County, July 2016 - Aug 2018*



8.4

12.012.6

11.0

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10.612.5

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SMALL FOR GESTATIONAL AGE BIRTH RATE

Small for gestational age (SGA) birth rate is the percent of births where only one baby was born whose weight at birth is at or below a set value (10th percentile) for the week of pregnancy they were born at2. SGA compares the birth weight of an infant to a national distribution of live births so the weights are specific to infants of the same gestational age. The value for the 10th percentile of birth weight was adopted from the live births for 1990 in the United States3. The health of the mother and social factors prior to pregnancy can influence if a child is born small for their gestational age2. SGA can have an impact on the health of the infant throughout childhood and into adulthood2. Babies who are born small for their gestational age have an increased risk for infant death and illness, permanent lack in growth, reduction or impairment of cognitive function, and the development of adult chronic disease2. The SGA birth rate in August 2018 is 12.0%, which is higher than the average SGA birth rate in Hamilton County (11.5%).

2. Association of Maternal & Child Health Programs. Life Course Indicator: Small for Gestational Age, 2014.3. Oken E, Kleinman KP, Rich-Edwards J, Gillman MW. A nearly continuous measure of birth weight for gestational age using a United States reference. BMC Pediatric. 2003; 3:6. doi: 10.1186/1471-2431-3-6.

NOTE: SGA Percent illustrated in Figure 6 is calculated using gender-specific small for gestational age 10th percentile cut-off for more accurate measures

August 2018, Page 6

Figure 6. Small for Gestational Age Rate Surveillance Chart, Hamilton County, July 2016 - Aug 2018*


12.0%August 2018

SGA Birth Rate

0%

10%

20%

30%

40%

50%

60%

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<6 Months 6-12 Months 12-18 Months > 18 MonthsHealthy People 2020 Goal (29.8%)

August 2018 Page 7

Figure 7. Percent of Pregnancies Spaced <18 Months, Hamilton County, July 2016 - Aug 2018*

NOTE: The mean is calculated using two years of data from Jul 2016 - Jun 2018 *Data for 2018 are provisional; ODH reconciles (i.e. finalizes) data by fall of the subsequent year.† Infant deaths to mothers with a previous live birth‡ Percentage of short spaced pregnancies does not include first time mothers or pregnancies where information pertaining to previous live birth was missing/unknownData Source: ODH Vital Statistics

PREGNANCY SPACINGPregnancy spacing is the number of months between the live birth of a previous child and the conception of the next pregnancy. It has been shown that short spacing between pregnancies, less than 18 months from the previous live birth to conception of the next pregnancy, can lead to harmful outcomes for both mothers and newborns. Mothers with short pregnancy spacing have an increased risk for developing pre-eclampsia (a condition that can cause blood pressure to rise and put mothers at risk for health issues including death), while the infant is more likely to be born prematurely. Pregnancies spaced between 18 and 59 months are considered optimal pregnancy spacing, as recommended by the World Health Organization4. Optimal spacing can lead to better outcomes for both the mother and the infant. However, for women of older ages, short pregnancy spacing may be part of the intended family building; in these cases women should talk with their doctor to weigh the health benefits of longer spacing between pregnancies and the health risks of short spacing between pregnancies. The percentage of pregnancies in Hamilton County that were spaced less than 18 months for August 2018 is 35.4%; this percent is higher than the Healthy People 2020 goal of 29.8% of all pregnancies spaced less than 18 months. Of the pregnancies between July 2016 and August 2018, 45.8% of pregnancies were spaced between 12 and 18 months. By educating mothers about the importance of properly spacing pregnancies, the risk for poor health complications for both mother and infant could be reduced.4. World Health Organization. Report of a WHO Technical Consultation on Birth Spacing, 2006

10.49.7

10.5

9.4 9.19.7

8.27.5

10.8

9.4

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6.7

8.8 8.9

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8.57.9 8.5

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August 2018, Page 8

Figure 8. Maternal Smoking Rate Surveillance Chart, Hamilton County, July 2016 - Aug 2018*


MATERNAL SMOKING RATESmoking, tobacco use, and other forms of substance use and abuse during pregnancy can be extremely harmful to a developing baby. Women who smoked during pregnancy in Hamilton County were 44% more likely to experience an infant death. The percentage of births in Hamilton County where the mother smoked in the 2nd or 3rd trimester (the last 6 months of pregnancy) for August 2018 was 8.8% (Figure 8). This was the same as the average number of births to women who reported smoking in the 2nd or 3rd trimester for Hamilton County (8.8%)

August 2018, Page 9

ALWAYS FOLLOW THE ABC’S OF SAFE SLEEP, EVEN DURING NAP TIME.

Baby sleeps safest alone, on their back, in a crib.

Alone Back Crib

Sleep-Related Deaths in Hamilton County, 2018 Year-to-Date

= 1 sleep-related death

SLEEP-RELATED DEATHSA sleep-related death is the death of an infant due to unsafe sleeping environments. A safe sleeping environment is one in which the infant is sleeping alone, on their back, and in a crib. Unsafe sleeping environments can consist of co-sleeping (a parent, adult or older child sharing a bed with an infant), an infant sleeping on a couch, an infant sleeping in a crib filled with blankets or pillows, or an infant being put to sleep on his/her stomach. There have been 11 sleep-related deaths in Hamilton County in 2018 so far. However, as further iterations of the report are published, the number of sleep-related deaths may change as records become finalized and complete.

9.0 9.7 8.59.3

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2-year IMR Moving Average Healthy People 2020 Goal (6.0)

August 2018, Page 10

TWO-YEAR MOVING AVERAGEReviewing monthly rates is one approach used to determine whether there has been a change over time in infant deaths. However, monthly rates have a tendency to fluctuate and may hide emerging trends. An alternative measure is the un-weighted, monthly moving average, which can provide a more stable picture of evolving patterns. In Figure 10, the infant mortality rate for each month is the 24-month average of months immediately prior to and including the current month. The two-year moving average has increased from August 2015 (9.0) to August 2018 (9.3) as shown in Figure 10. Please note that the two-year moving average is subject to change based on new data, which may ultimately affect current trends. Multiple approaches are required to measure the impact of efforts to reduce infant mortality.

Figure 10. Two-Year Moving Average Infant Mortality Rate by Month, Hamilton County, Aug 2015 - Aug 2018*

NOTE: The infant mortality rate for each month in the average of the 24 months immediately prior to and including the last month.*Data for 2018 are provisional; ODH reconciles (i.e. finalizes) data by fall of the subsequent year.Data Source: ODH Vital Statistics


CRADLE CINCINNATI’S CORNERExtreme preterm birth (before 28 weeks gestation) is the leading cause of infant death in Hamilton County. In fact, 56.3% of all infant deaths between 2011 and 2015 were babies who were born extremely preterm. This means 286 of the extremely preterm babies born didn’t survive.A variety of factors can contribute to preterm birth, including smoking during pregnancy. In Hamilton County, about 1 in 10 women report smoking during the 2nd and 3rd trimesters of their pregnancies. Recent studies show that underreported tobacco use may as much as double that number.A slew of smoking cessation resources – in-person, over the phone and via text – are available to women in Cincinnati. Prenatal health centers serving low-income moms are now using the 5A’s of smoking cessation to help their patients quit during pregnancy and stay smoke free. The Ohio Tobacco Quitline offers moms-to-be monetary incentives to quit smoking – up to $70 total. Learn more about these and other resources here.In addition, Cradle Cincinnati recently launched a new community initiative, employing women from English Woods and North Fairmount to build neighborhood-level movements around smoking cessation. In two years, we hope to cut maternal smoking in these two neighborhoods by half.Join us in our goal of helping moms-to-be quit smoking and stay smoke free. Learn more about maternal smoking cessation by visiting our website or emailing us at [email protected]. You can also learn more about preterm birth in Hamilton County here.

For more information, check us out on-line at www.cradlecincinnati.org, and follow us on social media:

@cradlecincy


OEI CORNERThe Cincinnati/Hamilton County Ohio Equity Institute (OEI) team is moving forward with a variety of activities to improve infant mortality rates in Cincinnati/Hamilton County. OEI focuses their upstream and downstream initiatives in two zip codes, 45225 and 45240. The upstream project focuses on incorporating a health education intervention into at least two school districts in Hamilton County. So far, the curriculum has been taught to all health & physical

education teachers within the 10 CPS Schools that were originally approved to be a part of the pilot project. We are currently in the implementation phase of the project and to this point the collaboration with CPS has been going well. The curriculum is composed of material that includes prevention of unintended pregnancy, sexually transmitted infection prevention, healthy relationships, and financial goal setting. We are still awaiting approval to implement in our second target district with Winton Woods Middle and High School.The downstream project connects new and expecting parents, caretakers (e.g. daycare/childcare staff), and extended family to peer advocates and needed resources in the priority ZIP codes of 45225 and 45240. Peer advocates will be conducting safe sleep and reproductive life planning trainings within priority ZIP codes and addressing family barriers. The safe sleep classes aim to teach expecting families and extended family members the ABC’s of safe sleep and why it is important. The reproductive life planning classes aim to raise awareness around the importance of spacing, family planning, and nutrition. After each of the classes, resources will be made available to participants. These resources include access to baby supplies, employment opportunities, connection to a Community Health Worker (if applicable), transportation, Job and Family Service applications, plus many more!


Table 2. Infant Mortality Data Source Assessment, Hamilton County, 2017-2018

There are multiple datasets that can be used to support surveillance activities associated with infant mortality. Two primary data sources are used to supply the data for the monthly Maternal and Infant Health Surveillance Reports (http://www.hamiltoncountyhealth.org/en/resource_library/reports.html). Both of these data sources are considered provisional until ODH completes data reconciliation process-es each year. Provisional Data Source A (PDS-A) contains records that correspond to filed certificates and are linkable (i.e., birth to death records), whereas Provisional Data Source B (PDS-B) contains records that correspond to both filed and unfiled/pending certificates and are not linkable. PDS-A is used for more in-depth analysis of risk factors, but suffers from incompleteness due to missing unfiled/pending certificates. PDS-B is used to collect death data more expeditiously, but provides only count data, pre-cluding more in-depth analysis of prenatal and perinatal risk factors. Data from both PDS-A and PDS-B become more accurate as the length of time increases from event to report. Annually, ODH releases a reconciled dataset that contains final cause of death information and geographic information. PDS-B is used in this report to provide the count statistics in each section except preterm births (Figure 3-5), small for gestational age (Figure 6), pregnancy spacing (Fig-ure 7), maternal smoking (Figure 8), and sleep-related deaths. Table 2 displays the discrepancy between the two infant mortality data sources from ODH. Please note that delayed certificates impact data quality, and therefore the integrity of findings shared in this report.

APPENDIX ADATA LIMITATIONS

2017 2018

Data Source Number of Infant Deaths

Number of Infant Deaths

PDS-A 96 68

PDS-B 96 68

Discrepancy 0 11

The Hamilton County Infant Mortality Surveillance System (HCIMSS) uses surveillance charts to monitor infant mortality rates, preterm birth rates, and other birth outcomes. These charts provide a method for monitoring the status of infant health over time and provide timely feedback on the effectiveness of local efforts to reduce infant deaths.Several tools are included in the surveillance charts that help facilitate interpretation:

1. A baseline - the center line which is the average number of deaths per month over the preceding two years,2. A goal line which shows the goal that has been established by the community,3. Upper and lower control limits (dashed) that allow user to detect unusual events.

Annotations indicate when certain interventions began or special changes occurred.Here are some types of unexpected events that could be detected within surveillance charts:

• A single point outside of the control limit• A run of eight or more consecutive points below or above the center line• Six consecutive decreasing or increasing points• Two out of three consecutive points near a control limit.

APPENDIX BGENERAL GUIDELINES FOR USING

SURVEILLANCE CHARTS

This report was prepared by Hamilton County Public Health, Department of Community Health Services, Division of Epidemiology and Assessment in collaboration with Cradle Cincinnati.

Thank you to John Paulson, Ohio Department of Health, Center for Public Health Statistics and Information, and Merrily Wholf, Ohio Bureau of Child and Family Health Services, for providing data for this report.

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Images courtesy of:Kelvin Murray via Getty Images | ©iStockphoto.com/ArtisticCaptures | ©iStockphoto.com/Christopher Futcher | ©iStockphoto.com/bo1982©iStockphoto.com/TatyanaGI | ©iStockphoto.com/Bruno Monteny

HAMILTON COUNTY...Very Preterm Birth Rate Surveillance Chart, Hamilton County, July 2016 - Aug 2018* Figure 5.

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